1 who-fic education committee 5 may 2006 training certifiers of cause of death roberto becker...

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WHO-FIC Education CommitteeWHO-FIC Education Committee5 May 20065 May 2006

WHO-FIC Education CommitteeWHO-FIC Education Committee5 May 20065 May 2006

Training Certifiers of cause of death

Roberto Becker

Training Certifiers of cause of death

Roberto Becker

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PreparationPreparationPreparationPreparation

• Workshop format• Who extends invitations• Time• Duration• Content / adaptations• Local examples

• Workshop format• Who extends invitations• Time• Duration• Content / adaptations• Local examples

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ContentContentContentContent

• Uses of mortality data• Role of the certifier• Work done with the information• International form for medical certification • How to certify• Special issues• Examples• Standard definitions• Exercises

• Uses of mortality data• Role of the certifier• Work done with the information• International form for medical certification • How to certify• Special issues• Examples• Standard definitions• Exercises

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The importance ofThe importance ofMortality statisticsMortality statisticsThe importance ofThe importance ofMortality statisticsMortality statistics

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USES OF MORTALITY DATAUSES OF MORTALITY DATA1. HEALTH SITUATION ANALYSIS1. HEALTH SITUATION ANALYSIS

USES OF MORTALITY DATAUSES OF MORTALITY DATA1. HEALTH SITUATION ANALYSIS1. HEALTH SITUATION ANALYSIS

WHO (SEX, AGE), WHEN, WHERE, WHAT CAUSE(S)

HOW LONG AND HOW THE PEOPLE LIVE HEALTH (INDIRECT) INDICATORS

CRUDE MORTALITY RATE LIFE EXPECTANCY / IMPACT OF THE CAUSES INFANT MORTALITY RATE MATERNAL MORTALITY RATE/RATIO YEARS OF POTENTIAL LIFE LOST SPECIFIC RATES (CAUSE, SEX, AGE)

MORTALITY DATA: MAIN INSTRUMENT TO IDENTIFY: PUBLIC HEALTH PROBLEMS GROUPS AT RISK NEEDS OF MEDICAL AND PUBLIC HEALTH RESEARCH

LEADING CAUSES OF DEATH - PRIORITIES

WHO (SEX, AGE), WHEN, WHERE, WHAT CAUSE(S)

HOW LONG AND HOW THE PEOPLE LIVE HEALTH (INDIRECT) INDICATORS

CRUDE MORTALITY RATE LIFE EXPECTANCY / IMPACT OF THE CAUSES INFANT MORTALITY RATE MATERNAL MORTALITY RATE/RATIO YEARS OF POTENTIAL LIFE LOST SPECIFIC RATES (CAUSE, SEX, AGE)

MORTALITY DATA: MAIN INSTRUMENT TO IDENTIFY: PUBLIC HEALTH PROBLEMS GROUPS AT RISK NEEDS OF MEDICAL AND PUBLIC HEALTH RESEARCH

LEADING CAUSES OF DEATH - PRIORITIES

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USES OF MORTALITY DATA USES OF MORTALITY DATA 2. EPIDEMIOLOGICAL SURVEILLANCE2. EPIDEMIOLOGICAL SURVEILLANCEUSES OF MORTALITY DATA USES OF MORTALITY DATA 2. EPIDEMIOLOGICAL SURVEILLANCE2. EPIDEMIOLOGICAL SURVEILLANCE

MAIN OR FIRST SOURCE OF DATA FOR SOME DISEASES OR CONDITIONS HIV/AIDS YELLOW FEVER RABIES ACCIDENTS AND POISONING VIOLENCE

USE AT LOCAL LEVELS LIST OF DIAGNOSTIC TERMS (PARALYSIS, IMMUNODEFICIENCY) INVESTIGATION CONFIRMATION OR CHANGE: CHECKING WITH STATISTICS SPECIFIC ACTIONS

GROUPS OF POPULATION WOMEN (MATERNAL MORTALITY) CHILDHOOD ADOLESCENCE ELDERLY

MAIN OR FIRST SOURCE OF DATA FOR SOME DISEASES OR CONDITIONS HIV/AIDS YELLOW FEVER RABIES ACCIDENTS AND POISONING VIOLENCE

USE AT LOCAL LEVELS LIST OF DIAGNOSTIC TERMS (PARALYSIS, IMMUNODEFICIENCY) INVESTIGATION CONFIRMATION OR CHANGE: CHECKING WITH STATISTICS SPECIFIC ACTIONS

GROUPS OF POPULATION WOMEN (MATERNAL MORTALITY) CHILDHOOD ADOLESCENCE ELDERLY

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USES OF MORTALITY DATAUSES OF MORTALITY DATA3. EVALUATION / INVESTIGATION3. EVALUATION / INVESTIGATION

USES OF MORTALITY DATAUSES OF MORTALITY DATA3. EVALUATION / INVESTIGATION3. EVALUATION / INVESTIGATION

QUALITY AND RESULTS OF HEALTH CARE MATERNAL MORTALITY CASE FATALITY RATE SURVIVAL

HEALTH PROGRAMS, SPECIFIC DISEASES / CONDITIONS VACCINE PREVENTABLE TUBERCULOSIS DIABETES CHOLERA HYPERTENSION ISCHEMIC HEART DISEASES NEOPLASMS ACCIDENTS AND VIOLENCE

TECHNOLOGY CASE FATALITY RATE (ACUTE DISEASES) SURVIVAL (CHRONIC DISEASES) NEOPLASMS HIV/AIDS

RISK FACTORS / MULTIPLE CAUSES / LINKED CAUSES

QUALITY AND RESULTS OF HEALTH CARE MATERNAL MORTALITY CASE FATALITY RATE SURVIVAL

HEALTH PROGRAMS, SPECIFIC DISEASES / CONDITIONS VACCINE PREVENTABLE TUBERCULOSIS DIABETES CHOLERA HYPERTENSION ISCHEMIC HEART DISEASES NEOPLASMS ACCIDENTS AND VIOLENCE

TECHNOLOGY CASE FATALITY RATE (ACUTE DISEASES) SURVIVAL (CHRONIC DISEASES) NEOPLASMS HIV/AIDS

RISK FACTORS / MULTIPLE CAUSES / LINKED CAUSES

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Medical Certification of MortalityMedical Certification of MortalityMedical Certification of MortalityMedical Certification of Mortality

• Legal – To certify the occurrence of a death– To define the nature: natural causes or not– Civil Registration / vital statistics

• Statistical – Demographic aspects: sex, age, ethnic group, residence,

socioeconomic data• Epidemiology / public health

– Cause(s)– Data for specific groups: infant and maternal deaths

• 1925 – Health Organization of League of Nations proposed a model for medical certification

• 1948 – ICD-6: Adopted as international form• 1950 – Worldwide use

• Legal – To certify the occurrence of a death– To define the nature: natural causes or not– Civil Registration / vital statistics

• Statistical – Demographic aspects: sex, age, ethnic group, residence,

socioeconomic data• Epidemiology / public health

– Cause(s)– Data for specific groups: infant and maternal deaths

• 1925 – Health Organization of League of Nations proposed a model for medical certification

• 1948 – ICD-6: Adopted as international form• 1950 – Worldwide use

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Work done with the informationWork done with the informationWork done with the informationWork done with the information

• Selection of underlying cause – Definition of Underlying cause– Coding diagnostic terms– General Principle, Sequences, Rules

• Validation and consistency– Cause by sex by age– Corrections

• Processing• Analysis • Decision making• Dissemination

• Selection of underlying cause – Definition of Underlying cause– Coding diagnostic terms– General Principle, Sequences, Rules

• Validation and consistency– Cause by sex by age– Corrections

• Processing• Analysis • Decision making• Dissemination

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INTERNATIONAL FORM OF MEDICAL INTERNATIONAL FORM OF MEDICAL CERTIFICATE CERTIFICATE OF CAUSE OF DEATHOF CAUSE OF DEATH INTERNATIONAL FORM OF MEDICAL INTERNATIONAL FORM OF MEDICAL CERTIFICATE CERTIFICATE OF CAUSE OF DEATHOF CAUSE OF DEATH

Cause of death approximate intervalIDisease or condition directly (a) .............................................................. ................leading to death due to (or as a consequence of)

Antecedent causes (b) ............................................................. ................Morbid conditions, if any due to (or as a consequence of) giving rise to the above causestating the underlying (c) ............................................................. ............... condition last due to (or as a consequence of) (d) ............................................................. ...............II Other significant conditionscontributing to the death, but ............................................................ ............... not related to the disease orcondition causing it ........................................................... ...............

Cause of death approximate intervalIDisease or condition directly (a) .............................................................. ................leading to death due to (or as a consequence of)

Antecedent causes (b) ............................................................. ................Morbid conditions, if any due to (or as a consequence of) giving rise to the above causestating the underlying (c) ............................................................. ............... condition last due to (or as a consequence of) (d) ............................................................. ...............II Other significant conditionscontributing to the death, but ............................................................ ............... not related to the disease orcondition causing it ........................................................... ...............

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Medical certificationMedical certificationMedical certificationMedical certification

Full information required, not only causes of death

Sequence • “a” due to “b” due to “c” due to “d”• Part I / Part II• Diagnoses per line

Use of Abbreviations • ARI, MI, etc.

Handwriting !

Full information required, not only causes of death

Sequence • “a” due to “b” due to “c” due to “d”• Part I / Part II• Diagnoses per line

Use of Abbreviations • ARI, MI, etc.

Handwriting !

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Special issuesSpecial issuesSpecial issuesSpecial issues

Avoided diagnoses • Suicide• AIDS• Tuberculosis• Drug/alcohol abuse

Manipulation of information (e. g. homicides, dengue)Injuries and poisoning Cardiac arrest infarction ?Incomplete and imprecise information

• Information on pregnancy• Pneumonia (etiology / hypostatic / terminal)• Infarction (acute or old / of the myocardium)• Endocarditis (acute or chronic / valve / rheumatic ?)• Senility / signs & symptoms• ARI

Avoided diagnoses • Suicide• AIDS• Tuberculosis• Drug/alcohol abuse

Manipulation of information (e. g. homicides, dengue)Injuries and poisoning Cardiac arrest infarction ?Incomplete and imprecise information

• Information on pregnancy• Pneumonia (etiology / hypostatic / terminal)• Infarction (acute or old / of the myocardium)• Endocarditis (acute or chronic / valve / rheumatic ?)• Senility / signs & symptoms• ARI

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Medical certification – Example 1Medical certification – Example 1Medical certification – Example 1Medical certification – Example 1

Female, 37 years• Admitted to an emergency room with generalized

edema, exertional dyspnea and ascites• Blood pressure 150 / 100, increased cardiac dullness

with 80 beats per minute,• Liver 5 fingers below the costal border• For a few years was being treated for chronic

glomerulonephritis • With the treatment her health situation improved a

little, with blood pressure oscillating between 150-180 / 100-120

• After one month her health situation deteriorated, dying in one week with pulmonary acute edema

Female, 37 years• Admitted to an emergency room with generalized

edema, exertional dyspnea and ascites• Blood pressure 150 / 100, increased cardiac dullness

with 80 beats per minute,• Liver 5 fingers below the costal border• For a few years was being treated for chronic

glomerulonephritis • With the treatment her health situation improved a

little, with blood pressure oscillating between 150-180 / 100-120

• After one month her health situation deteriorated, dying in one week with pulmonary acute edema

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Medical certification – Example 1Medical certification – Example 1

Original certificate

I a) Hypertension b) Pulmonary edema c) d) II Old nephritis

Medical certification – Example 1Medical certification – Example 1

Original certificate

I a) Hypertension b) Pulmonary edema c) d) II Old nephritis

Correct certificate

I a) Acute pulmonary edema terminal b) Hypertensive cardiopathy years c) Chronic glomerulonephritis years d)II

Correct certificate

I a) Acute pulmonary edema terminal b) Hypertensive cardiopathy years c) Chronic glomerulonephritis years d)II

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Deaths due to gastroenteritis, Bahia, Brazil, 1984Deaths due to gastroenteritis, Bahia, Brazil, 1984

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Deaths due to/With gastroenteritis, Bahia, Brazil, 1984Deaths due to/With gastroenteritis, Bahia, Brazil, 1984

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Medical certification – Example 2Medical certification – Example 2Attending physician vs. CoronerAttending physician vs. CoronerMedical certification – Example 2Medical certification – Example 2Attending physician vs. CoronerAttending physician vs. Coroner

Coroner:

I a) Bronchopneumonia and gastroenteritis b)

Attending physician:

I a) Bronchopneumonia b) gastroenteritis

Coroner:

I a) Bronchopneumonia and gastroenteritis b)

Attending physician:

I a) Bronchopneumonia b) gastroenteritis

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STANDARDIZATION OF CONCEPTS STANDARDIZATION OF CONCEPTS AND DEFINITIONSAND DEFINITIONS

STANDARDIZATION OF CONCEPTS STANDARDIZATION OF CONCEPTS AND DEFINITIONSAND DEFINITIONS

LIVE BIRTHS FETAL DEATH

ABORTION STILLBIRTH

PERINATAL PERIOD (28/22 WEEKS - 7 DAYS) PERINATAL MORTALITY

NEONATAL PERIOD EARLY LATE

CONDITIONS ORIGINATING IN THE PERINATAL PERIOD INFANT MORTALITY

NEONATAL LATE OR POST NEONATAL

MATERNAL MORTALITY RATE / RATIO LATE MATERNAL DEATH PREGNANCY RELATED DEATH

LIVE BIRTHS FETAL DEATH

ABORTION STILLBIRTH

PERINATAL PERIOD (28/22 WEEKS - 7 DAYS) PERINATAL MORTALITY

NEONATAL PERIOD EARLY LATE

CONDITIONS ORIGINATING IN THE PERINATAL PERIOD INFANT MORTALITY

NEONATAL LATE OR POST NEONATAL

MATERNAL MORTALITY RATE / RATIO LATE MATERNAL DEATH PREGNANCY RELATED DEATH

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CASE 1CASE 1CASE 1CASE 1

Female, 30 years

• A month before the admission she had several hematemesis episodes and, since then, deterioration of her general condition, extreme pallor and frequent melena. On the day of the hospitalization (18/11), new hematemesis. At the physical examination: Blood pressure 80/ 60 mm/Hg, pulse 128/ min, good hydration, pale mucous membranes (+++), `spleen at 1 finger, smooth, and hard liver at 1 finger. In view of the fact that the patient came from a schistosomiasis endemic area, the clinical diagnosis was rupture of esophageal varices due to portal hypertension due to liver fibrosis schistosomiasis. This diagnosis was confirmed subsequently by liver biopsy. In addition the species of the helminth was established as "mansoni". The tamponade of the varices was not satisfactory. Operated (19/11): splenectomy and ligature of the cardiotuberositarious veins. The hematemesis persisted and the patient died in irreversible shock on 22/11. Necropsy was not done.

Female, 30 years

• A month before the admission she had several hematemesis episodes and, since then, deterioration of her general condition, extreme pallor and frequent melena. On the day of the hospitalization (18/11), new hematemesis. At the physical examination: Blood pressure 80/ 60 mm/Hg, pulse 128/ min, good hydration, pale mucous membranes (+++), `spleen at 1 finger, smooth, and hard liver at 1 finger. In view of the fact that the patient came from a schistosomiasis endemic area, the clinical diagnosis was rupture of esophageal varices due to portal hypertension due to liver fibrosis schistosomiasis. This diagnosis was confirmed subsequently by liver biopsy. In addition the species of the helminth was established as "mansoni". The tamponade of the varices was not satisfactory. Operated (19/11): splenectomy and ligature of the cardiotuberositarious veins. The hematemesis persisted and the patient died in irreversible shock on 22/11. Necropsy was not done.

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CASE 1

I a) Rupture of esophageal varices 1 month b) Liver fibrosis years c) Schistosomiasis mansoni years d)II

CASE 1

I a) Rupture of esophageal varices 1 month b) Liver fibrosis years c) Schistosomiasis mansoni years d)II

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Female, 66 years• Has had rheumatic fever for 30 years, with mitral

stenosis as a complication. Five years ago began presenting congestive cardiac failure with compensation after treatment. The condition recently worsened, the cardiac failure becoming irreversible and the patient died. Four years ago it was confirmed that she had hypertension, with measurements that ranged between 160-190 / 100-120.

Female, 66 years• Has had rheumatic fever for 30 years, with mitral

stenosis as a complication. Five years ago began presenting congestive cardiac failure with compensation after treatment. The condition recently worsened, the cardiac failure becoming irreversible and the patient died. Four years ago it was confirmed that she had hypertension, with measurements that ranged between 160-190 / 100-120.

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CASE 2

I a) Congestive cardiac failure 5 years b) Mitral stenosis 30 years c) Rheumatic fever 30 years d)II Hypertension

CASE 2

I a) Congestive cardiac failure 5 years b) Mitral stenosis 30 years c) Rheumatic fever 30 years d)II Hypertension

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Male, 72 years• Ten months ago the patient was operated on for cancer

in the upper part of the stomach (verified histopathologically). He subsequently presented pulmonary metastases and his clinical condition deteriorated progressively. One week before death he presented bronchopneumonia. The patient was hypertensive for many years and 3 months before death had a stroke, remaining hemiplegic.

Male, 72 years• Ten months ago the patient was operated on for cancer

in the upper part of the stomach (verified histopathologically). He subsequently presented pulmonary metastases and his clinical condition deteriorated progressively. One week before death he presented bronchopneumonia. The patient was hypertensive for many years and 3 months before death had a stroke, remaining hemiplegic.

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CASE 3

I a) Bronchopneumonia 7 days b) Pulmonary metastases months c) Stomach cancer, upper part 10 + months d)II Hypertension years Stroke 3 months

CASE 3

I a) Bronchopneumonia 7 days b) Pulmonary metastases months c) Stomach cancer, upper part 10 + months d)II Hypertension years Stroke 3 months

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Female, 3 years• Girl with Tetralogy of Fallot, doing relatively well, in

preparation to being submitted to surgery. One morning she was found dead by her mother.

Female, 3 years• Girl with Tetralogy of Fallot, doing relatively well, in

preparation to being submitted to surgery. One morning she was found dead by her mother.

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CASE 4CASE 4

I a) Tetralogy of Fallot 3 years b) c) d)II

CASE 4CASE 4

I a) Tetralogy of Fallot 3 years b) c) d)II

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Male, 42 years• The mason was working on a scaffolding, at the twelfth

floor when accidentally fell to the ground, dying instantaneously. The Coroner reported multiple injuries (skull, hip and limbs).

Male, 42 years• The mason was working on a scaffolding, at the twelfth

floor when accidentally fell to the ground, dying instantaneously. The Coroner reported multiple injuries (skull, hip and limbs).

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CASE 5

I a) Multiple injury of head, hip, and limbs b) Accidental fall from scaffolding while working

c) d)II

CASE 5

I a) Multiple injury of head, hip, and limbs b) Accidental fall from scaffolding while working

c) d)II

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Female, 50 years• Two years ago the patient found nodes in the left

breast. At the medical examination presented great increase of the breast, retracted nipple, and palpable axillary nodes. She was taken to surgery in the month of April with diagnosis of malignant neoplasm of the breast with nodal metastases, with confirmation by surgery and by biopsy. She stayed well for four months, when her general health condition began to deteriorate, presenting increased volume of a nodular liver, jaundice and ascites. Two days before dying she entered in hepatic coma, well documented clinically and by laboratory. The patient died in December of the same year and an autopsy was not performed.

Female, 50 years• Two years ago the patient found nodes in the left

breast. At the medical examination presented great increase of the breast, retracted nipple, and palpable axillary nodes. She was taken to surgery in the month of April with diagnosis of malignant neoplasm of the breast with nodal metastases, with confirmation by surgery and by biopsy. She stayed well for four months, when her general health condition began to deteriorate, presenting increased volume of a nodular liver, jaundice and ascites. Two days before dying she entered in hepatic coma, well documented clinically and by laboratory. The patient died in December of the same year and an autopsy was not performed.

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CASECASE 6 6

I a) Hepatic coma 2 days b) Liver metastases months c) Malignant neoplasm of central part of the breast 2 yrs d)II

CASECASE 6 6

I a) Hepatic coma 2 days b) Liver metastases months c) Malignant neoplasm of central part of the breast 2 yrs d)II

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Male, 3 hours• Child born of spontaneous delivery in poor condition

(Apgar score of 2). The pregnancy was normal up to the eighth month, when the mother started to present vaginal hemorrhage, not seeking assistance during the first 24 hours. She was then taken to the hospital where was she admitted with pre-shock. The diagnosis made was hemorrhagic abruptio placentae. The baby was born cyanotic with signs of anoxia, dying in three hours.

Male, 3 hours• Child born of spontaneous delivery in poor condition

(Apgar score of 2). The pregnancy was normal up to the eighth month, when the mother started to present vaginal hemorrhage, not seeking assistance during the first 24 hours. She was then taken to the hospital where was she admitted with pre-shock. The diagnosis made was hemorrhagic abruptio placentae. The baby was born cyanotic with signs of anoxia, dying in three hours.

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CASE 7CASE 7

I a) Anoxia 3 hours b) Hemorrhagic abruptio placentae 2 days c) d)• II

CASE 7CASE 7

I a) Anoxia 3 hours b) Hemorrhagic abruptio placentae 2 days c) d)• II

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Male, 55 years• Two years before his death, the patient had an acute

myocardial infarction, confirmed by electrocardiogram. From then on he began to present affective type mental disorders, with frequent episodes of depression and weeping.

In the morning of the day of the death, at home, he shot himself in the chest with a handgun. Taken to the hospital, he died at two o’clock in the afternoon of the same day. Autopsy: Hemothorax (2 liters) and perforation of the upper lobe of the left lung.

Male, 55 years• Two years before his death, the patient had an acute

myocardial infarction, confirmed by electrocardiogram. From then on he began to present affective type mental disorders, with frequent episodes of depression and weeping.

In the morning of the day of the death, at home, he shot himself in the chest with a handgun. Taken to the hospital, he died at two o’clock in the afternoon of the same day. Autopsy: Hemothorax (2 liters) and perforation of the upper lobe of the left lung.

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CASECASE 8 8

I a) Hemothorax hours b) Perforation of upper lobe of the left lung hours c) Suicide by handgun shot at home hours d)II Acute myocardial infarction 2 years Recurrent depressive disorders

CASECASE 8 8

I a) Hemothorax hours b) Perforation of upper lobe of the left lung hours c) Suicide by handgun shot at home hours d)II Acute myocardial infarction 2 years Recurrent depressive disorders

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Female, 71 years• The patient, with a diagnosis of adenocarcinoma of uterine body

(verified by biopsy), had a panhysterectomy, followed by chemotherapy and blood transfusions. The patient had an old hypertension (220/ 140) that was being controlled with hypotensors and hyponatremic diet. One year and a half after the surgery she had symptoms of unconsciousness, with deviation of the mouth toward the left, right hemiplegia with patellar hyperreflexia and Babinski. She was treated as having had a stroke, with partial recovery. On the day of the death, two weeks after the beginning of this last episode, she presented deep coma with total areflexia, dying after a few hours, without recovering. The examination of the cerebral spinal liquid revealed hemorrhage.

Female, 71 years• The patient, with a diagnosis of adenocarcinoma of uterine body

(verified by biopsy), had a panhysterectomy, followed by chemotherapy and blood transfusions. The patient had an old hypertension (220/ 140) that was being controlled with hypotensors and hyponatremic diet. One year and a half after the surgery she had symptoms of unconsciousness, with deviation of the mouth toward the left, right hemiplegia with patellar hyperreflexia and Babinski. She was treated as having had a stroke, with partial recovery. On the day of the death, two weeks after the beginning of this last episode, she presented deep coma with total areflexia, dying after a few hours, without recovering. The examination of the cerebral spinal liquid revealed hemorrhage.

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CASECASE 9 9

I a) Coma hours b) Hemiplegia 2 weeks c) Stroke 2 weeks d) Hypertension yearsII Adenocarcinoma of uterine body 2 years

CASECASE 9 9

I a) Coma hours b) Hemiplegia 2 weeks c) Stroke 2 weeks d) Hypertension yearsII Adenocarcinoma of uterine body 2 years

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Female, 32 years• The patient was admitted in shock on the emergency service.

She was found at the end of the eighth month of pregnancy and she had had only two prenatal visits (fourth and fifth months). This was the fourth pregnancy and the previous ones were normal, with healthy live births. The blood pressure could not be measured, and the pulse was fine and tachycardic (140 p/min). Intense anemia of mucous membranes. According to family information, she had had genital hemorrhage for more than one week, at the beginning with little intensity, but increasing progressively. For two days she was in the bed and today, upon getting up has fainted. The family then brought her to the emergency room. Diagnoses: Acute anemia from hemorrhage due to placenta previa. Dead fetus. The mother was submitted to a caesarean, the death occurring just after the surgery.

Female, 32 years• The patient was admitted in shock on the emergency service.

She was found at the end of the eighth month of pregnancy and she had had only two prenatal visits (fourth and fifth months). This was the fourth pregnancy and the previous ones were normal, with healthy live births. The blood pressure could not be measured, and the pulse was fine and tachycardic (140 p/min). Intense anemia of mucous membranes. According to family information, she had had genital hemorrhage for more than one week, at the beginning with little intensity, but increasing progressively. For two days she was in the bed and today, upon getting up has fainted. The family then brought her to the emergency room. Diagnoses: Acute anemia from hemorrhage due to placenta previa. Dead fetus. The mother was submitted to a caesarean, the death occurring just after the surgery.

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CASECASE 10 10

I a) Acute anemia b) Uterine hemorrhage 1 week c) Placenta previa 1 week d)II Caesarean Section Pregnancy of 8 months

CASECASE 10 10

I a) Acute anemia b) Uterine hemorrhage 1 week c) Placenta previa 1 week d)II Caesarean Section Pregnancy of 8 months

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Male, 26 years• Three years ago was diagnosed as carrier of HIV, not

having any clinical manifestation until ten months ago, when he began to present fever, intense weight loss and a great deal of cough. The diagnosis of AIDS was made and also of tuberculosis of lung. He evolved very poorly, did not respond to the treatment, developed a bronchopneumonia, dying in four days.

Male, 26 years• Three years ago was diagnosed as carrier of HIV, not

having any clinical manifestation until ten months ago, when he began to present fever, intense weight loss and a great deal of cough. The diagnosis of AIDS was made and also of tuberculosis of lung. He evolved very poorly, did not respond to the treatment, developed a bronchopneumonia, dying in four days.

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CASECASE 11 11

I a) Bronchopneumonia 4 days b) Tuberculosis of lung 10 months c) Acquired Immunodeficiency Syndrome 10 months d)II Weight loss

CASECASE 11 11

I a) Bronchopneumonia 4 days b) Tuberculosis of lung 10 months c) Acquired Immunodeficiency Syndrome 10 months d)II Weight loss

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Female, 64 years• The lady was exiting a small minibus, taking advantage

of the red traffic light, and was hit by a motorcycle, which passed over her abdomen. She was removed alive to an emergency service. At the physical examination she presented signs of rupture of the spleen. A splenectomy was done. The patient lost 1.9 liters of blood and died before the end of the surgery.

Female, 64 years• The lady was exiting a small minibus, taking advantage

of the red traffic light, and was hit by a motorcycle, which passed over her abdomen. She was removed alive to an emergency service. At the physical examination she presented signs of rupture of the spleen. A splenectomy was done. The patient lost 1.9 liters of blood and died before the end of the surgery.

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CASECASE 12 12

I a) Acute hemorrhage b) Rupture of the spleen c) Hit by a motorcycle while exiting a minibus d)II Splenectomy

CASECASE 12 12

I a) Acute hemorrhage b) Rupture of the spleen c) Hit by a motorcycle while exiting a minibus d)II Splenectomy

1 who-fic education committee 5 may 2006 training certifiers of cause of death roberto becker...

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